One of the challenges with PTSD is that your patients can almost seem like they're stuck in the past. So they may be ruminating about the traumatic event. They may be thinking about it over and over and over again. What I mean by rumination is it's a little different than those intrusive memories that just pop up in the person's head or may occur while they're in the middle of doing something else. This is a more active process where the person keeps going back repetitively over the memory or going back through those thoughts like why me, why me, why did this happen? Trying to undo the past. Now the problem with that past focus is first of all it makes it harder for people to have hope for the future or to see themselves in the present but also rumination itself can be a form of avoidance.
This can be perplexing. My patient's thinking about the traumatic event all the time. How is it that they're avoiding? But the thing with rumination is it's not active problem solving. It's not moving them forward in any useful way. It's a little bit like a car that the wheels are stuck in the mud and they're just spinning, but they're not actually moving forward. There are several strategies you can use with patients who do seem to be stuck in the past or stuck in that ruminative type of pattern.
One strategy is to just do the work of processing the traumatic event and trying to reduce that avoidance. Sometimes this is something that naturally fixes itself as you're working on the PTSD. For people where this is a more ingrained pattern or where this seems to be a predominant form of avoidance, you may actually have to work with them to limit the rumination. Strategies like setting a time for the rumination and a time limit can be particularly helpful in shifting this behavior.
It is interesting when someone has to sit down and ruminate for twenty minutes, all of a sudden it loses a lot of its appeal. This also can be helpful for the patients who are engaging in catastrophic thinking. The person may be thinking about the future rather than the past, but they're still doing it in this wheel spinning nonproductive and avoidant way. Same strategies work, limit it, have the person keep track of the worries, and then just focus on it during that specific time that they've set aside for rumination.